Most medical board examinations in the United States are in the form of multiple-choice questions (MCQs). In order to answer these questions well and get high scores, it is important that residency and fellowship physicians understand how a multiple-choice question is created. This article will take you through this process and suggest strategies to answer them correctly. The features highlighted here are similar to the general guidelines given by various boards (USMLE, NBME, ECFMG, ABIM Internal medicine boards, ABP Pediatric boards etc.) to writers of multiple choice questions and medical residency programs. If you understand the following information, you will be able to recognize what the board question is testing you about and answer appropriately.

Synthesis questions - these require you to interpret medical facts, lab values and solve simple problems. You have to connect the dots, making use of the clues given in the USMLE question.

Clinical decision-making questions - these are usually tested by USMLE, Internal medicine, Family practice, Pediatrics & other boards. These questions require advanced clinical skills. They test a combination of medical knowledge, synthesis of information, interpretation of medical facts and making clinical decisions (Judgment) on the best course of appropriate medical action.

The two step question

In these types of questions, the stem gives a medical story and the lead line (question) is not "what is the medical diagnosis". Instead, the question is "what is the next appropriate action to take". Here you first have to make a medical diagnosis (for your own benefit), and then make a clinical decision on the next best course of action (for answering the question).
Patient-encounter locations for USMLE, Internal medicine boards.
Most multiple-choice questions are written to represent a clinical scenario that you are likely to encounter in real life. They describe a patient with several medical problems who presents to you for diagnosis and medical management. Most USMLE / Medical board questions are written to represent three common medical situations or patient encounter locations.

Emergency Room (ER)

Hospital (Inpatient setting)

Clinic or medical Office (Out patient setting)

Once this clinical scenario is set, and the long medical story is given, you will be asked a question (lead line) at the very end. There will be 4 or 5 choices given as possible answers and you will be asked to select one correct answer. You will then be required to enter the correct answer on the computer screen (answer sheet for paper based exams). USMLE Step 1, Step 2, and Step 3 are given as computer based tests. The American Board of Internal Medicine (ABIM) is now a computerized exam. Most other medical boards are looking into computerized test administration.

Multiple choice questions are written is such a way that, most USMLE examinees and physicians can easily eliminate 2 or 3 choices right away. Once the choices are narrowed down to 2 or 3, only a well-read physician will be able to select the correct answer.

Strategies for answering USMLE and other medical board exams

Study common disease conditions, as this is likely to be the majority content in the board exams. Don't spend too much time studying rare diseases and syndromes.

Cheap is good: For exam purposes, try to choose the least expensive test, and the least invasive procedure.

USMLE Step 1 exam is usually fact based. USMLE Step 2 exam usually tests your ability to make diagnosis by synthesis of medical facts and lab data. USMLE Step 3 and Internal medicine boards usually test your ability at clinical decision-making and medical management. The medical diagnosis is either given or implied in the question.

Focus on the lead line: The lead line of a question is usually very specific about the information asked and gives a clue to the testing objective of the question.

Asymptomatic patients: If the question talks about an asymptomatic, otherwise healthy patient whose medical condition was found only by accident or at a routine physical, the answer is usually observation or do nothing now. The testing objective here is to make sure you don't consider medical interventions where none is needed. However, keep in mind that this may not be true for all the questions and the answer depends on the patients specific medical condition.

Technical mistakes: The following are some technical mistakes that question writers make and may give clues to the correct answer. These have been systematically removed from the board exam question banks. So, don't rely on them to help you guess the correct answer.

The correct answer is much longer than the other choices given.

Grammatical mistakes: if the last word of the lead line of the question is "an", you would infer the first letter of the correct choice would be an vowel (a, e, i, o, u)

Two of the choices basically say the same thing: Then both may be false choices (both cannot be the correct answer).

Two choices say the opposite thing: Then one of them may be the correct answer.

Guessing: if you have no idea what the answer is, pick one answer (guess) and move on. There is no point wasting too much time on one particular question. This is especially true when answering medical statistics questions.

Time management: Most USMLE exam takers have a problem with finishing the test in time. It is important to realize that you cannot get all the questions correct. Besides, you don't have to get all questions correct to get a good score. So plan your exam strategy wisely and try to finish in time.

Think backwards: If you have no clue what the correct answer is, try to think backwards. Read the lead line and stem of the question once more and try to guess what the testing objective of the question is. Then pick the choice that corresponds to this testing objective.

Avoid choosing answers with absolute words like always, never, etc.

If all of the above is one of the options, and you are trying to guess, pick it.

General guidelines given to Physician question writers

Most guidelines ask board exam question writers to avoid including ambiguous information as it may mislead examinees. However, it is inevitable that you will find some ambiguous content in your questions.

Question writers are also asked to avoid ambiguous terms in the question's lead line. These include "commonly, rarely, usually, frequently" etc which can be misinterpreted by USMLE or Internal medicine board exam takers.

The purpose of each question is to test one "teaching principle". The teaching principle becomes the "testing objective" of the question.

The lead line of a question should be very specific about the information asked and should represent the testing objective of the question.

Good medical board question: A good question is constructed in such a way that a well-read physician from a residency or fellowship program is able to pick the correct answer from the choices given.

Bad board question: A bad question is constructed in such a way that a well-read physician from a residency or fellowship program wrongly answers the question because of confusing choices.

All choices must represent genuine medical information. For example, a choice should not be a made up syndrome name.

Questions should be straightforward and not tricky. The object of the exam is not to trick examinees. It is to test each physician's medical knowledge and clinical problem solving ability.

Each question must test only one teaching principle. Testing more than one teaching principle should be avoided in a single question. For examples on teaching principles and testing objectives, refer to MKSAP multiple-choice questions and accompanying explanations.

Board questions and testing objectives should represent diseases seen in daily medical practice. Common conditions like Diabetes, chest pain, MI, COPD, vaginal infections, Hypertension, Obesity etc., will be given importance and may be the majority of the exam content.

Rare diseases are not usually tested, except if that disease can be potentially life threatening.

Board question writers have been asked to avoid negative questions. For example, "All of the following choices are correct EXCEPT".

When presenting the choices, only one must be the correct answer. Controversial choices must be avoided. A well-read physician from a residency or fellowship program should be able to pick the correct answer.

The incorrect choices presented are called distracters. Distracters are usually partially correct, but not fully correct.

Avoid using all of the above and none of the above, as answer choices.